Citation Nr: 21000037 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 16-17 297 DATE: January 4, 2021 ORDER Entitlement to service connection for post-traumatic stress disorder (PTSD) is denied. Entitlement to service connection for an acquired psychiatric disorder to include an adjustment disorder with anxiety is granted. Entitlement to service connection for tachycardia, to include as secondary to an acquired psychiatric disorder is granted. Entitlement to service connection for hypertension, to include as secondary to PTSD is denied. FINDINGS OF FACT 1. Throughout the entire appellate period, the Veteran has not been diagnosed with a PTSD under DSM-IV or DSM-V criteria. 2. Resolving all doubts in favor of the Veteran, his adjustment disorder with anxiety is etiologically related to his in-service personal assault by seven servicemen. 3. Resolving all doubts in favor of the Veteran, his tachycardia is proximately caused or aggravated by his service-connected adjustment disorder with anxiety. 4. Resolving all doubts in favor of the Veteran, his hypertension is proximately caused or aggravated by his service-connected adjustment disorder with anxiety. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1112, 1113,1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for service connection for an adjustment disorder with anxiety have been met. 38 U.S.C. §§ 1112, 1113,1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 3. The criteria for service connection for tachycardia, to include as secondary to PTSD have been met. 38 U.S.C. §§ 1112, 1113,1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 4. The criteria for service connection for hypertension, to include as secondary to PTSD have been met. 38 U.S.C. §§ 1112, 1113,1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from October 1969. He also served in the United States Army from February 1970 and from January 1971 to January 1973. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In March 2019, the Veteran testified before the undersigned Veterans Law Judge during a Board video conference hearing. These matters were previously before the Board in September 2019 but were remanded to afford the Veteran a VA examination. In a July 2020 supplemental statement of the case (SSOC), these claims for service connection for were denied. These matters are again before the Board for adjudication. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131. Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a). Service connection may also be granted for chronic disabilities, such as psychoses or organic diseases of the nervous system, when manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309 (2018). VA will also grant service connection on a secondary basis. Service connection on a secondary basis is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Acquired psychiatric disorder to include post-traumatic stress disorder (PTSD) and adjustment disorder with anxiety The Veteran seeks service connection for his acquired psychiatric disability to include PTSD and an adjustment disorder with anxiety. Specifically, he contends his acquired psychiatric disabilities are related to his personal assault by seven servicemen in Germany. Establishing service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (under the criteria of American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM)), a link, established by medical evidence, between current symptoms and an in-service stressor, and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 4.125 (2016). There generally must be independent evidence to corroborate the Veteran’s statement as to the occurrence of the stressor. Doran v. Brown, 6 Vet. App. 283, 288-89 (1994). The PTSD regulations include provisions pertinent to veterans with combat-related stressors, stressors founded on fear of hostile military or terrorist activity, stressors based on being a prisoner of war, and stressors based on personal assault. Upon review of the evidence, the Board finds that the Veteran has not been diagnosed with PTSD under the Diagnostic and Statistical Manual of Mental Disorder (DSM) IV or V. The Veteran has reported an in-service stressor indicating he was personally assaulted by up to seven servicemen in Germany and his service treatment record (STRs) indicates he was treated for injuries related to a fight in 1971. However, an August 2013 VA examiner stated his symptoms did not meet the diagnostic criteria for PTSD under DSM-IV criteria. His VA treatment reflects he was seen in January 2016 by a VA advanced practicing nurse (APN) for his anxiety. While he reported the in-service personal assault to the APN, upon conclusion of that examination, the APN noted a diagnosis of anxiety. See February 2016 CAPRI. Subsequent counseling sessions with a VA licensed clinical social worker in 2016, 2019, and 2020 shows he was receiving treatment for anxiety disorder and adjustment disorder. However, there is still no evidence that he was diagnosed with PTSD. Additionally, in a January 2020 VA examination, the VA examiner noted the Veteran’s claim that he developed PTSD symptoms following an incident where he was attacked by a group of African American soldiers. However, the VA examiner stated there is no evidence that his symptoms ever met the diagnostic criteria for PTSD. The VA examiner explained that in order to meet the criteria, there has to be evidence of significant clinical distress or functional impairment. The VA examiner noted the Veteran reported that he has “always been able to keep them under control” and denied any functional impairment. The Veteran also reported that he has “an amazing life” with a loving family, friends, hobbies, and a successful career that included multiple businesses. The Board acknowledge the Veteran’s belief that he has PTSD and has relayed symptoms such as recurring flashbacks of the personal assault in Germany. While the Veteran is competent to report symptoms of his psychiatric disorder, the Board finds that he is not competent to provide a diagnosis of PTSD. VA regulations requires a PTSD diagnosis be made by a psychiatrist or psychologist. The Veteran has not demonstrated any specialized knowledge or expertise to indicate he is capable of rendering a competent medical diagnosis. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As such, he is not competent to provide a PTSD diagnosis. In this regard, the Board finds that preponderance of the medical evidence fails to show a competent diagnosis of PTSD, the first element necessary to establish service connection is not met. Therefore, his claim for service connection for PTSD is denied. With regards to the Veteran’s adjustment disorder with anxiety, the Board finds that service connection is warranted. The Veteran’s medical record shows that he has a current diagnosis of a psychiatric disorder as he was diagnosed with an anxiety disorder and an adjustment disorder throughout the period on appeal. See July 2020 CAPRI. With regards to an in-service event, injury, or illness, the Veteran reported he was personally assaulted during service by up to seven servicemen in June 1971. A review of his STRs further shows he was treated for injuries to his head, ribs, and mouth in 1971. As such, an in-service event has been met. With regards to a medical nexus, the Board finds that there are competing evidence. In an August 2013 VA examination, the VA examiner noted the Veteran has psychosocial stressors which likely contribute to his anxiety. He reported his spouse had significant health problems and the family suffers from financial strain. Additionally, he was at the age of retirement but due to the uncertainty of finances he would be unable to retire within the foreseeable future. As such, the VA examiner concluded that while it was at least as likely as not that the Veteran suffers from an anxiety disorder, it appears to be greatly aggravated by recent psychosocial stressors. A January 2014 VA examiner also opined that it was less likely than not that his current anxiety is related to the assault in 1971. The VA examiner noted the Veteran’s STRs shows he was treated for contusion, bruising, and trauma to the mouth related to being beaten in June 1971. However, the VA examiner noted he had no history of mental health treatment and his December 1971 separation examination was negative for any psychiatric concerns. The VA examiner further reiterated the August 2013 VA examiner’s conclusion that he is likely experiencing anxiety associated with current financial and health related stressors. A January 2020 VA examiner further opined that it was less likely than not that his adjustment disorder with anxiety was incurred by the claimed in-service event. The VA examiner stated his current diagnosis of adjustment disorder with anxiety is in response to life stressors including his wife’s health problems, financial stress, and his own health problems. The VA examiner further noted the Veteran has discussed the in-service incident and his “PTSD” symptoms with five different medical providers in the VA but was never diagnosed with PTSD. Rather he was consistently diagnosed with anxiety disorder in 2013 and 2016 and more recently updated to adjustment disorder in 2019. Nevertheless, the VA examiner stated that the records suggest that his symptoms were caused by life stressors at the time and not by the in-service event. The VA examiner further noted the Veteran discussed the in-service event with a VA licensed clinical social worker at their initial meeting but noted their remaining sessions focused on coping with life stressors. However, a review of the Veteran’s January 2016 VA treatment record shows he was undergoing cognitive behavioral therapy to deal with his anxiety. During a January 2016 VA mental health note, the Veteran reported his in-service assault, having flashbacks, anxiety, and avoidance of a group of young black men, and that his heart beats faster and he has knee jerk gut reaction when things remind him of the past. As such, a VA licensed clinical social worker assessed that the Veteran appears to have anxiety and anger issues related to being attacked while in Germany. Subsequent VA mental health notes from January 2016 to April 2016 continues to show the Veteran’s ongoing treatment and management of his anxiety that are related to provoking situations such as having irrational beliefs that groups of individuals are going to hurt him. His VA mental health notes consistently reflect his inability to forgive the men who assaulted him during his VA mental health treatment sessions in 2016 and again in 2020. See July 2020 CAPRI. Upon the Board’s review of these medical evidence, while the August 2013 VA examiner stated that the Veteran’s anxiety disorder was greatly aggravated by psychosocial stressors, the VA examiner did not take into consideration or adequately address whether the Veteran’s anxiety is related to his in-service personal assault. As such, the Board affords little probative weight to this medical opinion. Similarly, the Board affords little probative weight to the January 2014 VA medical opinion as it based solely on the absence of contemporaneous treatment for an acquired psychiatric condition. Further, while the January 202 the VA examiner states his anxiety disorder is related to psychosocial stressors and that he only discussed the in-service personal assault with his mental health provider initial and was seen for life stressors for his remaining sessions, this seems to be a generalization of his VA mental health sessions. As provided above, the Veteran was seen and treated with cognitive behavioral therapy to help him cope with his anxiety disorder on more than on occasion. Upon the Board’s consideration of the Veteran’s competent and credible lay statements regarding the in-service event and his symptoms, the VA medical opinions, and his VA mental health treatment records, the Board finds that the evidence is in equipoise. Thus, in resolving all doubts in favor of the Veteran, the Board finds that he is entitled to service connection for adjustment disorder with anxiety. Therefore, his claim is granted. 2. Hypertension, to include as secondary to PTSD 3. Supraventricular tachycardia (SVT), to include as secondary to PTSD The Veteran seeks service connection for his hypertension and SVT disability. Specifically, he asserts that his hypertension and SVT are related to his flashbacks. See March 2014 Notice of Disagreement. Upon review of the evidence, the Board initially finds that the Veteran is not entitled to service connection for his hypertension disability as directly due to service. The Board finds that the Veteran has a current diagnosis of hypertension and SVT as reflected in an August 2013 VA examination. However, the Veteran does not assert that his hypertension and SVT disability was incurred in service. Further review of his STRs also fails to show that he complained of any symptoms related to these disabilities or that he was treated or diagnosed with the disabilities in service. As noted in an August 2013 VA examination, it was not until 2008 that the Veteran reported he was diagnosed with hypertension and SVT after being taken to a hospital for feeling extremely fatigued and having a very high pulse rate. Thus, the Board finds there is no in-service incurrence of hypertension or SVT and direct service connection must be denied. With regards to whether the Veteran is entitled to secondary service connection for his hypertension, he has a current diagnosis of hypertension and SVT. He is also now service connected for his adjustment disorder with anxiety. With regards to whether there is a medical nexus relating his hypertension and to his adjustment disorder, the Board finds there are conflicting medical opinions of record. In an August 2013 VA examination, a VA examiner opined that that his hypertension and tachycardia was at least as likely as not proximately due to or the result of his service-connected condition. The VA examiner provided that he had worsening PTSD-like symptoms which coincided with his supraventricular tachycardia (SVT), anxiety, and hypertension diagnosis five years ago. The VA examiner noted the Veteran reported symptoms of irritability, hypervigilance, and exaggerated response. The Veteran also reported some annoying and disruptive behavior at home, avoids socialization, and complains of flashbacks and continued sleep disturbances. The VA examiner stated these types of behaviors are known to be associated with increased catecholamine and other excitatory neurotransmitter release which can contribute to the development of hypertension or aggravate existing hypertension. The VA examiner stated his development of hypertension coincides with the escalation of his symptoms of PTSD, although he has not received a diagnosis until the present examination. The VA examiner further stated that PTSD can trigger anxiety and panic attacks which can increase heart rate and rhythm and have many physical manifestations. The VA examiner noted the Veteran has no other risk factors, such as CAD, history of MI or obesity that have contributed to his medical conditions. The VA examiner also stated that it is not possible to quantify the degree to which the PTSD has worsened the veteran’s hypertension beyond its normal progression without resorting to mere speculation. In a January 2014 VA examination, a VA examiner opined that the Veteran’s tachycardia and hypertension are less likely than not caused by or worsened by a service-connected anxiety or PTSD disability. The VA examiner stated that there is no diagnosis by mental health professionals that his diagnosed anxiety disorder or PTSD is a result of an event or condition that occurred in military service. The VA examiner stated that while a non-VA cardiologist referenced that the etiology of his SVT was due to anxiety or stress, the reference was made without any knowledge or reference to any event in military service. The VA examiner further stated tis i less than likely that the symptoms of tachycardia and/or hypertension are related to any anxiety related to service with two mental health specialists finding no etiological link to service. The VA examiner further added that the presence of SVT and hypertension both controlled with metoprolol appear related to events or conditions other than military service based on evaluation of the evidence. Moreover, the VA examiner stated that his hypertension is stated to be “essential hypertension” which is more than likely caused by race, history of hypertension in or both parents, high sodium intake, excess weight, and physical inactivity. In sum, the Board finds there are two VA opinions, one relating to the Veteran’s hypertension and tachycardia to his anxiety disorder or PTSD and one negative opinion stating that his hypertension and tachycardia is not proximately caused or aggravated by his anxiety disorder. While these VA medical opinions are conflicting, both VA examiners supported their opinion with adequate medical bases. The Board finds that overall, the evidence is at least evenly balanced as to whether the Veteran’s current hypertension and tachycardia disability is proximately caused or aggravated by the Veteran’s adjustment disorder with anxiety. Giving the benefit of the doubt to the Veteran, the Board finds that the Veteran’s current hypertension and SVT are proximately caused or aggravated by his service-connected adjustment disorder with anxiety. Thus, secondary service for his hypertension and SVT is warranted. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Xiong, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.